Clinical Challenges of Rehabilitation in Periodontal Disease

Why Is Prosthetic Rehabilitation Challenging?

The most clinically challenging phase of the dental implant surgeon or the prosthodontist is to restore the form, function, and esthetics in a periodontally compromised patient. In patients suffering from periodontal diseases, the dentition may be severely affected or significantly weakened due to underlying bone loss when left untreated by the dentist for a long time.

The current advanced implant therapy is also a limitation for severely compromised periodontal patients. In periodontal disease, there is a significant loss of bone volumes that need substitution or regrowth to enhance the phenomenon of osseointegration, be it in partially edentulous or completely edentulous patients.

Osseointegration of implants or the prosthetic rehabilitation of missing teeth with crown or bridge poses a problem owing to the loss of bone volume due to periodontal disease. The dentist hence frequently adopts a conservative strategy for most patients who refuse full mouth rehabilitation by attempting to maintain as many natural teeth as possible after periodontal gum surgery and treatment.

What Are the Types of Implant Prosthesis Used in Periodontally Compromised Patients?

There are mainly two types of prosthesis that support dental implants in partially or completely edentulous patients suffering from periodontal disease. These include:

• TRP (telescopic retained retrievable prosthesis).

• FP (full arch fixed prosthesis).

The implantologist can implement this prosthetic rehabilitation after one clinical session of ATP or active periodontal therapy. ATP can be adopted as a therapeutic or surgical treatment strategy for those patients who refuse either because of economy or fear of safety, or dental phobias to procedures like complex bone grafts or sinus augmentation procedures.

What Is Active Periodontal Therapy (APT)?

Active periodontal therapy or APT mainly involves the periodontist or the maxillofacial surgeon adopting a series of procedures to aid bone regeneration and growth to compensate for the volume loss due to disease. The dental surgeon throughout performs periodontal assessment, and then if needed, flap surgery can be achieved.

An essential step before implementing active periodontal therapy is the assessment of furcation involvement of the teeth. The dentist would mainly diagnose furcation involvement on clinical probing, and debridement surgeries can be performed in the furcation area with the help of certain diamond-coated sonic scalers during the flap surgery.

Other accessory procedures like pocket elimination surgery, regeneration procedures, bone grafts, and osseous resection are all only additionally attempted if absolutely indicated in the periodontally compromised patient.

What Is Splinting and Supportive Periodontal Therapy?

The choice to extract severely compromised remaining teeth in a partially edentulous patient depends upon the dentist alone after active periodontal therapy. Supposing the teeth in question have a hopeless prognosis. It is indeed unpredictable, as even after the initial phase of periodontal treatment, the teeth have failed to respond to periodontal surgical therapy in such cases. Also, if periodontitis is eliminated or at least prevented from reoccurrence for some time, then full-arch fixed bridges are a good option recommended by the dentist, prosthodontist, or implantologist to successfully maintain the fixed bridges on a minimal number of abutment teeth.

Periodontally affected teeth that have responded to treatment in terms of tooth health but still have not regained any gingival or bone support and remain mobile can be splinted to retain them as abutments for the fixed bridge prosthesis. However, the question of the lifespan of such mobile teeth affected by weak periodontal support is always in doubt despite rigorous oral hygiene and frequent dental checkups. This is because the bone support is severely impacted, which has caused tooth mobility.

Still, evidence shows that such splinted teeth can also last with a 90 % survival rate, especially if the patient maintains good oral hygiene and follow-up dental visits that assure long-term prosthetic success. Splinting, however, is only a final option, according to the prosthetic surgeon, as it is mainly to enhance patient comfort. SPT or supportive periodontal therapy by the dentist is a significant factor that shows substantial improvement in the long-term success rates of the implant or crown and bridge prosthesis.

For Whom Is a Dental Implant Prosthesis Unsuitable?

With regular supportive periodontal therapy, evidence shows that bone loss can be significantly prevented even after the prosthetic rehabilitation of the patient in the long term. Furthermore, the all-on-four concept of implant rehabilitation is also an advanced strategic modality that helps replace all the periodontally compromised teeth with a hopeless prognosis. This is done by extracting all the remaining teeth in the patient and then replacing them with dental implants using the novel "all-on-four" concept.

Dental literature shows that this prosthetic implant strategy works with a 99.8 % survival rate for more than 24 months in patients who are ideal for dental implantation, which again depends on the factors like age of the individual, the bone volume, the bone density, and the period of edentulism or periodontal disease. Implant strategies may not work favorably in patients with altered immune responses, cellular stress, or immunocompromised bone healing (as in various general systemic conditions, syndromes, disorders, or STDs).

Hence proper, timely assessment by the prosthodontist or the implantologist for tooth replacement or for adopting active and supportive periodontal therapies before prosthetic rehabilitation treatment will prove highly productive in successful long-term outcomes.

Conclusion:

To conclude, prosthetic rehabilitation be it by an implant or fixed prosthesis, is a clinically challenging phenomenon for the dentist that requires careful assessment of periodontal parameters, the prognosis of the teeth in question, patient cost factors, risk of complications, and patient's expectations of comfort and convenience. Hence, active periodontal therapy before rehabilitation and supportive periodontal therapy after rehabilitation will help long-term prosthetic success in periodontally compromised patients.